Provider Demographics
NPI:1417963240
Name:GILLES, CHRISTINA GORMASTIC (DPT)
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:GORMASTIC
Last Name:GILLES
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:CHRISTINA
Other - Middle Name:MARIE
Other - Last Name:GORMASTIC
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DPT
Mailing Address - Street 1:PO BOX 950248
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40295-0248
Mailing Address - Country:US
Mailing Address - Phone:502-489-5730
Mailing Address - Fax:502-489-5733
Practice Address - Street 1:3303 FERN VALLEY RD
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40213-3529
Practice Address - Country:US
Practice Address - Phone:502-964-4889
Practice Address - Fax:502-964-9769
Is Sole Proprietor?:No
Enumeration Date:2006-08-01
Last Update Date:2020-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY004448174400000X, 225100000X
IN05008800A225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
KY000000064465OtherANTHEM/BCBS
KY0717712Medicare PIN
KY000000064465OtherANTHEM/BCBS
KY186592Medicare ID - Type Unspecified